Section 16 (pp. MEDCOM 3318-3412)

From dKosopedia

Synopsis Section 16: MEDCOM 3318-MEDCOM 3412

NOTE: I am NOT a clinician. I do work in medical research and have some familiarity with medical terminology and pharmacology especially in regards to anesthesia.

SYNOPSIS: Section 16 MEDCOM 3318-3325 (Part of patient file continued in Section 15 pages 92 - 100 MEDCOM 3309 - 3317)

Patient - Arghani male "claiming to be" 16 years old - had previous bullet wound to L[eft] hip and while at IDF [Detainee/Detention Facility?] was escorted to bathroom where he broke into a cold sweat, urinated on himself and complained of dizziness. He was examined, an IV started and was transported by ambulance to medical facility on 12 Aug 02. He was hydrated, given Motrin and Dilantin. Patient refused to ambulate - medical personnel indicated belief he was being "uncooperative" - and was discharged to IDF without crutches on 15 Aug 02.

SYNOPSIS: Section 16 Pages 9 - 36 MEDCOM 3326 - 3353

Patient 25 yo Afghani male was airlifted for care on 29 June 03 after receiving flash burns from a grenade explosion on 25 or 26 June 03. Surgery was performed followed by several days of pain management, wound treatment and dressing. Patient discharge appears to have been to "home". Follow up instructions are "by local provider when you return home" and type of disposition is "05".

SYNOPSIS Section 16 Pages 37 - 46 MEDCOM 3354 - 3363

Patient presents with a 3 day old traumatic injury to the 3,4,5 digits of his right hand. His fingers were reportedly caught in a tractor fan and patient initially denied treatment but has now reconsidered. This story is repeated at several points - pg 39 "35 y/o local national tractor injury to (R) hand x3 days. Hand caught in fan blade of tractor injuring 3 fingers. Initial visit treated and irrigated [] Pt denied wanting to fly to BAF for surgical tx. Now [up arrow] pain has decided he wants to get it fixed." (More text follows.) Patient was x-rayed, treated and released with simple pain med and bandage instructions. "Distal amputation of Middle Finger" noted on consult and treatment chart.

SYNOPSIS Section 16 Pages 47 - 63 MEDCOM 3364 - 3380

Patient is a 37 yo male Muslim who presents with a bullet lodged deep in his Right thigh/posterior. Patient arrives for surgical consult after being treated as local hospital. Surgery is performed and the bullet removed. Patient is discharged with follow-up drugs and instructions for 5 days post-release. Type of disposition is again "05".

SYNOPSIS Section 16 Pages 64 - 86 MEDCOM 3381 - 3403

Patient is 23 yo Afghan Muslim male suffering from a gunshot wound to his left lower leg and resulting leg fractures. Patient under goes surgery and has pain control initially of morphine and then percocet. Patient drinks water with difficulty, complains of pain and spends much time outside of his room complaining that the smell of the other patient in the room gives him headaches. He is discharged to "home" with crutches, percocet, dressing change instructions and directed to return for a follow-up to "Bagram 452 in one months 11-7-03". Note: The discharge paper is noted as "City of Kandahr" at the top of the nursing record page 66 MEDCOM 3383. The patient is repeatedly referred to as "local Afghan" on his nursing chart.

Page Summary Section 16: MEDCOM 3318-MEDCOM 3412

[NOTE: Charts seems to have been scanned from top to bottom so reports often run in reverse order. eg The first page is discharge notice.]

Pages 1-8: MEDCOM 3318-3325 of this archive are part of patient file continued in Section 15 pages 92-100 MEDCOM 3309-3317

Pages 1-2 MEDCOM 3318-3319 Lab Reports Dated 12,13 Aug 02

Page 3 MEDCOM 3320 Radiological Consult "Normal CT head" report or request

Page 4 MEDCOM 3321 Doctor's Orders Notes on admission and drug order

Page 5 MEDCOM 3322 Doctor's Orders 15 Aug 02 Discharge Today

Page 6 MEDCOM 3323 Therapeutic Plan Care notes. Foley Cath etc.

Page 7 MEDCOM 3324 Therapeutic Plan Drug dispensed record form IV fluids and Dilantin

Page 8 MEDCOM 3325 Admissions Form 12 Aug 02 1500 "PUC AFGHAN MALE 16y~ [approx. patient claimed 16 years but caregivers expressed doubt] MUSLIM

Page 9 MEDCOM 3326 Inpatient Treatment Record Cover Sheet [Usually final sheet composed when patient discharged] "Afghan Adult Male M 25 Race UNK[nown] Muslim Ward ICW Type Case INS Hours of Admissions 2321 Type of Disposition 05 [?] Date of Disposition 03 July 03 Date of Admission 29 Jun 03 [Redacted] Bagram, Afghanastan" [sic]

Page 10 MEDCOM 3327 Chronological Record of Medical Case [Handwritten-clearly some medical terms need to be corrected here.] "29 Jun 03 Admit 2329 25yo sustained flash burns 2[degree] to gernade attack on 25 Jun 03. Initially seen at FST [Field Station Hospital?] wound detrazidement [?] done. PMHo/PSHx-Denies. MEDS-0 ALL-NKDA Afeb Sa02 RA = 95% Alert. MMM. ~20-30% Facial Burns RRR S. S2 Back injury CTA(B) ARD-Soft NT/ND + LE Burns (B) Hands & distal LE Burns. LABS a/p Flash Burns 2nd [degree] to Grenade Attack >IVF [IV Fluids] > Pain management >Dr. [redacted] to see pt [redacted] / CP5IMC"

Pages 11-13 MEDCOM 3328-3330 Chronological Record of Case 3 pages of handwritten notes about the case. Most dealing with bandage changes and wound treating post-operatively. Note good progress of patient.

Page 14 MEDCOM 3331 Nursing discharge sheet. Discharge is listed to "home". Medications, treatments and follow-up care listed.

Pages 15-16 MEDCOM 3332-3333 Intraoperative documents Patient noted as "calm" and drug treatment is listed.

Page 17 MEDCOM 3334 Vital signs chart tracking patient temp and blood pressure.

Page 18 MEDCOM 3335 Lab results

Page 19 MEDCOM 3335 Pre-anesthetic report. Mostly blank or "unknown" with note "Burns".

Pages 22-24 MEDCOM 3339-3341 Clinical Records Doctor's Orders Three pages of doctor's notes-admission through discharge.

Pages 25-27 MEDCOM 3342-3344 The first two pages are care orders and plan. Last page is medications.

Page 28-29 MEDCOM 3345-3346 Aeromedical Evacuation Patient Record Description of wounds and evaluation for medical air transport. "Originating Facility KAF Destination Facility BAF"

Page 30 Intra Operative Document

Page 31 Lab Results

Page 32 Anesthesia Record

Page 34-35 MEDCOM 3351-3352

Page 36 MEDCOM 3353 Admissions form "30 YO Afghan Adult Male 10% BSA 2[degree] burns"

Page 37 MEDCOM 3354 Patient Treatment Cover Sheet 03 Aug 17-03 Aug 18 Treatment Center is listed as "[redacted] Afghaninstan". M 35 Muslim

Page 38 MEDCOM 3355 Brief handwritten progress notes

Page 39 MEDCOM 3356 Chronological Record of Care Handwritten account of patient story as well as drugs and treatment.

Page 40 MEDCOM 3357 Emergency Care and Treatment Sheet Handwritten form filled out.

Page 41 MEDCOM 3358 Nursing Discharge Summary Notes Tylenol #3 given and instructions for dressing care and changing.

Pages 42-43 MEDCOM 3359-3360 Intraoperative Document

Pages 44 MEDCOM 3361 Lab Results

Page 45 MEDCOM 3362 Radiological consult sheet for treatment.

Page 46 MEDCOM 3363 Patient Admission and Coding Form Treatment Facility: [Redacted] Bagram Afghanistan "35 YO Muslim Race:9 FMP:20 Beneficiary: K78 Type of Disposition: 05"

Page 47 MEDCOM 3364 Inpatient Treatment Coversheet "M 37 Muslim Ward: ICW Type Case: BC Date of Disposition: 03 Sept 27 Date of Admission: 03 Sept 26

GSW [gunshot wound] (R) buttock retained [?] bullet. reatined bullet (R) posterior medial deep upper thigh-buttock"

Page 48 MEDCOM 3365 Progress Notes [handwritten] Notes on initial consultation and decision of surgery. "Admit Note Surg Consult 9/26/03 11:25 Patient [illegible] rifle GSW (R) buttock [] debraded in Ghazni local hospital presents for consideration of removal & other injuries." [more] Discharge assessment follows on page dated 9/27/03

Page 49 MEDCOM 3366 Emergency Care and Treatment form Patient arrives by ambulance is examined and admitted "General Surgery". Wound description and initial vitals noted.

Page 50 MEDCOM 3367 Nursing Discharge form Medications: Keflex (antibiotic), Percocet (painkiller) Dressing change notes and "follow up in 5 days (02 Oct 03)"

Page 51 MEDCOM 3368 Highly redacted "Civil affairs" note.

Page 52 MEDCOM 3369 Flowsheet for Vital Signs 3 entries

Page 53 MEDCOM 3370 Lab results

Page 54 MEDCOM 3371 Anes flowsheet General LMA Vitals noted [within expected limits] Drugs administered [Normal Anes drugs]

Pages 55-56 MEDCOM 3372-3373 Radiological Consult Request Two pages of x-ray consults. Most notes involve placement of bullet. "Bullet lodged approx 4 cm below syphysu pubiu" [?]

Page 57 MEDCOM 3374 Request of Consent of Anesthesia Patient Consent form. NOTE: First consent form I've seen in medical documents.

Page 58 MEDCOM 3375 Clinical Record Doctor's Orders Handwritten notes with usual redactions.

Pages 59-62 MEDCOM 3376-3379 Therapeutic Documentation Care Plan Non-medication and medication plan notes.

Page 63 MEDCOM 3380 Admission Form Redacted Admission form for patient. Same information.

Page 64 MEDCOM 3381 Patient Treatment Record Cover Sheet Summary sheet states date of admission "01 Oct 03" and a type disposition of "Home" on 07 Oct 03.

Page 65 MEDCOM 3382

Pages 81 MEDCOM 3389 Radiological Consult Request One page of x-ray consults. Most notes involve fracture damage to leg. "[] Fracture of distal tibia No detectable Fibula Fx"

Page 82-83 MEDCOM 3399-3400 Clinical Record Doctor's Orders Handwritten notes with usual redactions.

Pages 84-85 MEDCOM 3401-3402 Therapeutic Documentation Care Plan Non-medication and medication plan notes.

Page 86 MEDCOM 3403 Admission sheet Admission at 1700 03/10/07. 23 yo Muslim male is admitted to the ICW. Authority of admission is marked as "0" [struck through zero].

NOTE: Rest of chart case spills into Section 17 - will post results when resolved